DUODENAL DIVERTICULA

Gastroenterology and hepatologyhospital-baghdad

31-10-2013

GI & hepatology hosp.-baghdad

Duodenal diverticula can be extraluminal or intraluminal.

EXTRALUMINAL DIVERTICULACause and PathogenesisExtraluminal duodenal diverticula are noted in about 5% ofupper gastrointestinal x-rays, and in about 25% of endoscopicretrograde cholangiopancreatography (ERCP) studiesor autopsies. They are thought to be acquired. They arisein an area of the duodenal wall where a vessel penetratesthe muscularis or where the dorsal and ventral pancreasfuse in embryologic development. Approximately 75% arelocated within 2 cm of the ampulla and are termed juxtapapillarydiverticula (JPD).

(sleisenger)

GI & hepatology hosp.-baghdad

Clinical Features and Diagnosis

Duodenal diverticula are typically diagnosed on upper gastrointestinal x-rays . They are easily missed on

endoscopy unless a side-viewing endoscope is used. The

sensitivity of computed tomography (CT) and magnetic

resonance imaging (MRI) for duodenal diverticula is

low. If a diverticulum is suspected on CT or MRI, the

diagnosis can be clarified by having the patient drink water and repeating the scan. The presence of an air-fluid level in

the structure will clarify the diagnosis. A duodenal diverticulum may be mistaken for a pancreatic pseudocyst, peripancreatic fluid collection, cystic pancreatic tumor, hypermetabolic mass, or distal common bile duct stone on ultrasound, CT, MRI, or positron emission tomography

(PET)-Ct

Problems associated with extraluminal duodenal

diverticula include perforation or diverticulitis, bleeding, acute pancreatitis, and common bile duct stones.

Bleeding has been reported from Dieulafoy like lesions or ulcers within diverticula Patients with multiple duodenal diverticula may develop

bacterial overgrowth and malabsorption Juxtapapillary diverticula have been associated withcommon bile duct stones, cholangitis, and recurrent pancreatitis.The presence of a juxtapapillary diverticulum hasbeen shown to lead to sphincter of Oddi dysfunction.Delayed emptying of the common bile duct may occur, evenafter sphincterotomy.Stasis within diverticula can result inlocal bacterial overgrowth, favoring deconjugation of bilirubinand thus increasing the risk of primary common bileduct stones.

Treatment and PrognosisExtraluminal duodenal diverticula rarely require

therapeutic intervention. Resection of duodenal diverticula should never be done for vague abdominal complaints.

Bleeding, diverticulitis, and perforation are the most common problems associated with duodenal diverticula. Endoscopic control of bleeding from diverticula has been accomplished

using various techniques, including bipolar cautery, epinephrine injection, and hemoclips

INTRALUMINAL DIVERTICULA

Intraluminal duodenal diverticula (windsock diverticula) are single saccular structures that originate in the second portion of the duodenum. They are connected to the entire circumference or only to part of the wall of the duodenum and may project as far distally as the fourth part of theduodenum.

There is often a second opening located eccentrically

in the sac (Fig. 23-9). Both sides of the diverticulum

are lined by duodenal mucosa. Fewer than 100 cases have been reported.

Intramural duodenaldiverticulum (windsock diverticulum).A, The diverticulum is attached to theentire duodenal circumference. B, Thediverticulum is attached to only part

of the duodenal circumference

Intraluminal diverticula may become symptomatic at any age. The most common symptoms are those of incomplete duodenal obstruction.

If the diagnosis is not made preoperatively, surgical control of bleeding can be accomplished through a duodenotomy.

Damage to the pancreatic and biliary ducts may occur during surgery in patients with periampullary diverticula. Most patients with perforation or diverticulitis undergo

laparotomy for diagnosis. The usual surgical treatment is drainage and resection of the

involved diverticulum, if feasible.If the diagnosis is made preoperatively, successful

conservative therapy by percutaneous drainage and antibiotics is possible

At endoscopy, an intraluminal diverticulum is a sac-like

structure with an eccentric aperture or a large, soft, polypoid mass if the diverticulum is inverted orad. Endoscopic diagnosis may be difficult.

A long sac may be mistaken for the duodenal lumen, whereas an inverted diverticulum may be mistaken for a large polyp. Gastric retention or dilation of the duodenal bulb may result from

chronic partial obstruction caused by the diverticulum.

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